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STATE OF CALIFORNM WATER RESOURCES CONTROr'fiOARD rz" <br /> FORM IA': <br /> UNDERGROUND STORAGE TANK PROGRAM S,P Rem <br /> SITE ���=- ��� <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> _ o <br /> L/ COMPLETE THIS FORM FOR EACH FACILITY/SITE .O.: <br /> atl, <br /> OnN <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT - o„ <br /> ONE ITEM ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ❑2 INTERIM PERMIT ❑q AMENDED PERMIT <br /> ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 2- <br /> FACILITY/SITE NAME <br /> EV,l' N/ln. CARE OF A/qD,D�RESS INFORMATION <br /> ADDRESS / - <br /> N REST CROSS STREET0 irAic 0 0 PARTNERSRIP 0 gATE <br /> CITY NAME .AGENLy N <br /> Cl cDRPDRATiON 0 IDCAI AGEN EEDERa acExcr N <br /> ❑ INprvIDpAL ❑ COGNtt-AGENCY <br /> STATE Z/IP�CODE SITE PH NE k,WITH AREA CODE <br /> TYPEOFBUSMESS: ❑2DISTRIBIROfl ❑gpfl00E�DR ✓ CIO <br /> Box it INDIAN EPA IDA `LSZAO� /V � <br /> �t GAS STATION ❑3FARM ❑50THER TRUST LANDS or ❑ RPI TANK'S <br /> EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 41st q �- PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> S _ PHONE M WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> �. <br /> MAILING ar STREET ADDRESS <br /> ✓ o indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> L E7 CORPORATION 11LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> ki STATE ZIPCODE PHONE R,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> SX CARE OF ADDRES"INFORMATION <br /> MAILING or STREET ADDRESS ��✓$ef to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> V� LTCORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE ONE p,WITH AREA CODE <br /> 141 — J <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WNICN ADM ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ N. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> \ APPLICANT'S NAME(PRINTED A SIGNATURE) DATE <br /> OCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY# FACILITY IDR R of TANKS K SITE <br /> N = = lololal=jzcoo <br /> CURRENT LOCAL AGENCY FACILITY ID R APP OVED BY NAME PHONE R MRN AREA CODE <br /> 9 Co 42 <br /> PERMIT NUMBER PERMIT APPROVAL DATE RMIT EXP) TION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR- ISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 YES ❑ NO <br /> ICHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> A DATA PROCESSING COPY '•,� <br />